General Pediatrics II

Anemia
Lead poisoning
Hypercholesterolemia
Developmental Dysplasia of Hip
Hypertension
Sports Injury
Childhood Injuries
Preventive Medicine

David Johnson, M.D.

A nine month old child has very pale

mucous membranes.
In children there is a physiologic anemia. Often it occurs - it peaks
between 2 and 3 months of age. Most children will get down to a
range of around 11 in about 3 months.

Anemia
Some people advocate screening between 9 and 12 months. Its

"Physiologic anemia" occurs 2-3 months

a peak age for iron deficiency if they have switched off iron
formulas. Some people advocate 24 months. Another point is that

Age

Hemoglobin

Range

(gm/dL)

if you do a peripheral hematocrit it could be lower than central so

that if they are anemic, you should probably do a central test. Just

2 weeks

16.5

13-20

3 months

12.0

9.5-14.5

a picture of a tiny child that can show up. Pale mucous membrane, pale skin. You see what are called red lines, concentrated

dense lines at the growth centers.

Timing of "screening" is controversial.

9-12 months - peak age for Fe deficit

24 months

Adolescence - especially in girls

Peripheral hematocrit may be lower than central

venous hematocrit

Lead Poisoning
Lead Poisoning. In the 1980s the average lead level was about

Sources of Lead

12. In 1991 the average lead level in our population was 3. Leaded

Lead-confining paint pre -1950's

paint has been eliminated for the most part in this country, but

Leaded gasoline - industrial lead

Fumes from burning batteries

Glazed ceramic vessels and folk medicines

even today some paint is still leaded. Leaded gasoline, industrial

lead, and car batteries and then all this miscellaneous. Sometime

#
#

lead-containing ceramic vessels. The point is that young children

are particularly at risk for lead poisoning because of their hand-to-

Young children are at risk thru hand-mouth exposure

mouth exposure. And also through the respiratory tract. In the past

and thru respiratory tract

we used to use the erythrocyte protoporphyrin test as a screen.

Testing

Its no longer recommended. It was only useful when sort of there

blood level - finger vs. venipuncture

were a lot of levels above 30. Venous lead level is the test to use.

Lead levels >10 deserve attention

You do a finger first and then you do a venipuncture if its elevated.

And the big news is, as most of you know this, is that we have
lowered our level of whats acceptable. Any child thats screened
that has a level of 10, an environmental assessment needs to be
done.

A four year old presents with a family

history of high cholesterol and coronary heart disease.

Hypercholesterolemia
Just to remind ourselves, total cholesterol is the low density which

Childhood symptoms of hyperlipidemia are very rare

is the bad guy, and high density which is the good guy and then

but may include xanthomas, corneal arcus, heart

triglycerides. If you have a family history you should consider

screening the child once they have reached two years of age. You

disease, and hypertension.

#

Family history will identify 40-60% of children with

hypercholesterolemia.

#
#
#

could probably do a random sample but if its high, you must do a

fasting level to really interpret it. If the total cholesterol is greater
than 200 you should obtain a lipid profile. Basically the acceptable

Total cholesterol = LDL-cholesterol + HDL-cholesterol

is a total amount less that 170 and an LDL lower than 110. Its

+ Triglycerides/5

borderline if the total is 170-199 and LDL is 110-129. High is

Secondary causes of high total cholesterol include

above 200. There is a reluctance to use cholesterol lowering

endocrine, renal and hepatic disorders, and drugs.

medicine in children. They certainly deserve nutritional counseling

Screening is recommended after age 2 for patients

and for selected families you might want to use drugs.

with a family history of hypercholesterolemia. A fasting

level is preferred.

NCEP Classification of Hyperlipidemia

Category

Total Choles-

LDL-choles-

terol

terol

Acceptable

<170

<110

Borderline

170-199

110-129

High

>200

>130

A two week old presents with a unilateral

"hip click".

Developmental Dysplasia of Hip

Dislocated Hip. Its new term is Developmental Dysplasia of the

#
#

The presentation can vary from mild instability to true

Hip. And it has to do with hips that are unstable and can come in

dislocation.

and out, versus those that are truly dislocated. And probably about

Incidence:

Dislocatable hip = 1:100

Frank dislocation = 1:1000

1:100 of newborn kids are actually dislocatable, where about

1:1000 are frankly dislocated at time of birth. The two main
symptomatologys are Barlows and thats where when you press

Clinical Examination

it from behind it comes out. And then Ortolani which when you are

Barlow. Pressure dislocates the joint

abducting it you can kind of feel it clunk as the hip goes back up,

Ortolani. "Clunk" is felt when joint is reduced

back into its out.

Galiazzi. Aymmetric skin folds are visualized

Limited abduction (>3 months)

Ultrasound best imaging test

A five year old boy is brought to the

office with a complaint of headaches.
Blood pressure is 120/70.

Hypertension
Whats important is that you use the right size blood pressure cuff.

Normal ranges for blood pressure varies at different

Never too small. It has to be right or a little large. It is recom-

ages.

mended that we take blood pressure annually after the third

Appropriate size BP cuff should be used.

Annual BP measurements are recommended for

birthday. In borderline cases anxiety can play a role.

asymptomatic children after age 3.

#

In borderline cases, anxiety may be responsible for the

hypertension, and serial measurements should be
obtained.

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Indications for Blood Pressure

Hypertension should be evaluated in three different occasions

Evaluation

suggesting hypertension include headaches, dizziness, visual

unless you are talking about excessively high levels. Symptoms

changes, seizures and the childs clinical encephalopathy. Renal

disease, cardiac disease, growth failure, seizures may be caused

Symptomatic Patients

by hypertension. And the acute ones are: having seizures, head

headaches

injuries, poisons and urinary changes, particularly hematuria.

dizziness

visual changes

seizures

Encephalopathy

vomiting

temperature elevation

ataxia

stupor

acute seizures

Chronic Conditions

renal disease

cardiac disease

growth failure

seizure disorder

Acute Conditions

seizures

head injury

poisonings

urinary changes

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A 12 year old boy presents for a sports

physical before joining a junior high school
football team.

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Sports Injury Prevention

Warming up and cooling down, overuse, avoidance, correct

Injury Prevention Strategies

biomechanics.

matched by age and size, particularly in contact sports. Protective

Conditioning: Appropriate Training, warming up

and cooling down, overuse avoidance, correct
biomechanics of sport.

You should be careful that the athletes are

equipment, proper treatment when there is an injury, and then ageappropriate training, specifically strength training. Weights should
only be used after Tanner 5 stage in boys. There is no handi-

Matching of athletes for size

capped child that shouldnt be able to participate in some sport.

Protective equipment

You might have to find that sport for that child but there is some

Proper treatment of injuries and rehabilitation

sport. Well children with chronic diseases like seizures and

Age-appropriate training

diabetes are not a contraindication for almost any sport, with the

Fluid replacement important during sweating

exception of something where a slight lapse of consciousness

could be dangerous, like scuba diving. Fluid replacements.
Children in general sweat. Everybodys sweat is hypertonic,
particularly young children, and the replacement fluid is water.
Rapid weight loss due to dehydration is dangerous.

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Morbidity in Children
There is an increasing association of illness in children associated

#
#

Childhood injury causes more deaths than all child-

living in poverty, which is related to poor nutrition, environmental

hood diseases combined.

pollution, crowding, and lack of health care. There is more illness

Illness is associated with poverty (eg, malnutrition,

pollution, crowding, lack of health care)

due to so-called risk-taking behaviors. Drug use, tobacco, sexually

transmitted disease, teenage pregnancy and violence in our
children, which is probably on the increase.

Illness is caused by risk-taking behaviors (e.g. drug

use, tobacco, STD, teenage pregnancy)

Violence against children

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Impact of Childhood Injuries

Childhood injuries. Every year in our country, there are 22,000

22,000 deaths annually age 19 and under

children who are killed by injuries. This mortality is the tip of the

600,000 hospitalizations

iceberg. There are at least 600,000 hospitalizations and

14,000,000 physician visits

14,000,000 physician visits for injuries. Motor vehicle accidents are

still the leading cause of death, both for pedestrians and occupants
of the car. But firearms has risen to second place so that 1 out of
5 children who are killed by injury are now killed by firearms.
Drowning, fire, choking, poisoning, falls, cuts are also causes.

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Injury Deaths, Age 0-19

With firearms, there is a 6:1 ratio of male to female; overall, boys

Cause

Male

Female

Total

Motor vehi-

42661

21438

64099

are 2 times more likely to be killed by injuries than females.

If you look by intent, and that is trying to get away from intentional

cle acci-

versus nonintentional, clearly most of the injuries are unintentional

dent

injuries so we have rates of 21 per 100,000. Suicide and homicide

are coming up there. These account for about 30% of the deaths.

Firearm

26504

4381

30885

Drowning

9481

2994

12475

Fire or

5421

3953

9374

Suffocation

5343

2261

7604

Cutting

1954

807

2761

70% of child injury deaths are unintentional and 30% qualify as

abuse, homicide or suicide.

flame

107,347
44,221
Total
Boys are at 2 1/2 times greater risk.

151,568

Ref: Injury to Children & Teenagers, Baker et al, 1996

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Injury Deaths by Intent Age 0-19

Total

Rate per
100,000/year

Unintentional

107,756

21.47

Suicide

15,424

3.07

Homicide

26,324

5.24

Unknown

2,064

0.41

151,568
30.20
Total
70% of Child Injury Deaths are Unintended Injuries

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Motor Vehicle Accidents

Motor vehicle accidents are the biggest cause of mortality. For

# Incidence of Motor Vehicle Accidents (<age 15)

Annually:

Involvement in car crash 1 in 50

Injury in car crash 1 in 200

# Unrestrained children are 2.7 times more likely to be

injured.

children under 15, 1 in 50 annually is involved in a car crash and

1 in 200 is injured in a car crash. Children who are not restrained
are 2.7 times more likely to be injured than those who were
properly restrained. And then overall for accidents, he found that
children were properly restrained in the car only 40% of the time
they were in the car accident. On the average, 21 children die
everyday in a motor vehicle accident. Not surprisingly, new drivers

# Children are properly restrained in cars in only 40%

are most common, 15 to 19-year-olds account for 63% of all these

# On average 21 child die in motor vehicle accidents each

deaths. Males to females is 2:1 and one-third of these children who

day.
# Children age 15 to 19 are the most at risk (63% of
deaths)

The male to female ratio is 2 to 1

One third of motor vehicle accidents are associated

were killed in car accidents had a blood alcohol level above the
legal limit for being intoxicated. For children less than age five, for
those that died, 63% of them were unrestrained in the car.

with a blood alcohol level of greater than 0.10%

For age under age 5 years, 63% of deaths occur

when the child is unrestrained

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Prevention of Motor Vehicle Accident Injury

So what are our interventions? First of all, the big one is car seats.
Birth to 20 lbs, infant seats are recommended, beyond that
convertible seats and booster seats up to about 40 lbs or age four

Recommendations:

Car seats

at which point they can go into the lap harness. The results are

Birth to 20 lbs: Infant seat

that child car seats do reduce the risk of death and serious injury

Birth to 40 lbs: Convertible

by 70% (properly used). So we know that proper use can prevent

seat

at least 500 deaths and 53,000 injuries. The current recommenda-

>30 to 40 lbs: Booster seat

#
#

Lap-harness >age 4

Child car seats reduce risk of death and serious

tion is that children under age 12 should always sit in the back
seat. There is one little exception and I've heard a lot of parents talk
about it. The infant who is still in the rear facing car seat and they
are put in the back and the parents can't see him. There have been

injury by 70%

a few reports now about premature babies who don't breathe well.

Proper use can prevent 500 deaths and 53,000

So, there are going to be ongoing issues and there is some

injuries annually

discussion about airbags being able to be disengaged.

One of things that we can really do is to tell our parents about the
use of proper car restraints and warn them in advance that this is
not one of those things parents negotiate on. All parents have to
pick their battles. You can't be the perfect parent on everything, but
there are some things you can compromise on and some things
you can't and I think the child who is never out of a car seat will
stop objecting. We all know that parents who let their kids out a
few times because they are tired are in for a battle forever.

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Childhood Poisonings
Childhood poisonings. The statistics tell us that there are 1.2

# 1.2 million episodes per year of poisoning in children

million episodes each year in children, resulting in 69,000 hospital-

# 69,000 hospitalizations per year

izations and a little under 550 deaths. Here again, though, this is

# 539 deaths per year

not pure accident. These are injuries are somewhat predictable. An

# Black children have a three-fold increased risk of death

African-American child under age nine in our country is three times

more likely to die from poisoning than a comparable child in other
ethnic groups. So it has to do with education and access and
supervision.

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Prevention of Childhood Poisonings

The practice of child-proofing a home has been stressed a lot in

Anticipatory Guidance. Telling parents, asking them, and giving
them handouts on how actually to childproof their home. Putting

# After age 6 months, "child proofing" is recommended

syrup of ipecac in their home along with phone numbers for poison

# Syrup of ipecac should be kept in the home

control centers so you have them.

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Baby Walkers
Baby walkers. At least 25,000 children less than 15 months of age

# 25,500 children per year are treated in emergency

departments for baby walker injuries

have been treated in ERs, most of them for falls, mostly down
steps.

# 83% of injuries involve children falling down stairs or

between steps

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Prevention of Baby Walker Injuries

We have tried to ban baby walkers. We do not recommend them.

Efforts to ban walkers have failed

It is not going to make the baby walk any sooner. They like their

Improved design (eg, no collapsible x-frame models)

kids upright. So what we can do is we can work to improve

Voluntary requirements: Size larger than basement

doorways, improved stability

structures. Certainly, there are no more collapsible x-frame

models. Those old models that used to collapse on them and pinch
fingers. They are going to come out with some voluntary requirements for manufacturers hoping to make the size larger than the
basement doorways.

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Firearm Safety
Firearms. Every day in our country, 102 people die from gunshot

# 102 people per day die from gun wounds, including 14

persons under the age of 20 years old.
# Firearm homicides are the leading cause of death in
black teenaged males and females
# A firearm in the home is 43 times more likely to kill
family or friends than to kill intruder
# 50% of children shot accidentally are shot in their home,
and 38% are shot in the home of relative or friend
# Suicide risk 5 times higher if a gun is present in the

wounds including 12 children under the age of 20. Firearm

homicide is the leading cause of death in our African-American
teenage males and females. There are 200 million guns. Sixty
seven million handguns. If you have a firearm in your home, you
are 43 times more likely to kill a family member or a friend than to
kill an intruder. Children are shot accidentally 50% of the time in
their own home and 38% of the time in a home of a relative or a
friend. There is a 5 times increased chance that there will be a
suicide if the home has a gun. In 1992 there were 13,000 people
in our country killed with guns of which 4,400 were children.

home
# Educational efforts should encourage gun storage and
safety. "If you keep a gun, empty it out and lock it up"

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Prevention Efforts: Age 0-10 years

What are some of our interventions? They are controversial and

# Child safely car seats < age 5

none of us have the right answer. There certainly have been, and

# Car lap-shoulder belts > age 5

should be, a need for more educational efforts about gun storage

# Bicycle helmets, bicycle safely

and safety. And again the American Academy says, "If you keep

# Smoke detector
# Hot water heater temperature (<120-130)

a gun, empty it out and lock it up."

Things that have been proven to improve their health. Child safety

# Window and stair guards, pool barriers

car seats. Car lap-shoulder belts after age 5. Bicycle helmets and

# Syrup of ipecac, poison control phone number

bicycle safety programs. Smoke detectors. Flame retardant

# Safe storage of poison, drugs, firearms, matches

materials. And lowering the hot water heater to 120. Window and

# CPR training of caregivers

stair guards, pool barriers. Syrup of ipecac, the poison control

phone number. Safe storage of poison, drugs, firearms, matches.
CPR training of caregivers in high risk situations.

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Prevention Efforts: Age 11-24

If you go to the older age group, it is not as clear that what we do

# Car lap and shoulder belts

makes a difference. Those things that have been proven are: use

# Bicycle and motorcycle helmets

of car lap/shoulder belt, bicycle and motorcycle helmet, using a

# Smoke detectors

helmet for all terrain vehicles, smoke detectors, and safe storage

# Safe storage and care of firearms

# Avoid tobacco use

of firearms.
Avoiding tobacco use. Avoidance of that tobacco use--our
educational efforts have been shown to be effective. But when we

# Avoid underage alcohol or illicit drug use

get to avoiding underage alcohol and drug use, it is not clear that

# Avoid alcohol or drugs with water sports

our training programs have made a difference. Avoid alcohol/drugs

# STD prevention

with water sports, STD prevention, abstinence, condoms.

# Abstinence, condoms
# Contraception

Injury deaths have decreased. The child death rate from injuries
has actually decreased by 26%. And this is majority due to
decreased poisonings, some decrease in our car accidents and
some improvement in pool safety features. Unintentional deaths,
"accidental deaths", have actually decreased almost by 40%. But
the bad news is that intentional injuries, which again only account
for 30% of the deaths, the homicide, suicide, child abuse, has
actually increased 47% in the last 14 years. So we are making
dramatic improvements.

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